Anatomy

Is a Labial Frenectomy Necessary After Braces?
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A couple of months ago, my sister called to ask my opinion about a frenectomy that the orthodontist had suggested for my nephew.  After discussing it with the orthodontist, my sister decided to postpone the frenectomy for the time being.

Is a Maxillary Labial Frenectomy Necessary?Since then, it seems that I’ve had more than a few questions about the necessity of a maxillary labial frenectomy on the post describing a labial frenectomy.

These questions seem to come from parents who are concerned about whether a surgical procedure is truly necessary to keep their child’s teeth straight after orthodontic treatment.  I don’t blame them for their concern.  I think that an unnecessary surgery is not only a waste of time and resources, but also introduces unnecessary risk to the patient.

In this article, I’ll take a look at at the leading textbooks on orthodontics and pediatric dentistry to see what they say about whether or not a frenectomy is necessary after having braces.  It’s important to note that a frenectomy should not be done during braces treatment as it is believed that the scar tissue formed may prevent the teeth from moving together, thus creating a permanent gap between the two front teeth.

A Labial Frenectomy After Braces – An Orthodontic Perspective

It seems that more and more orthodontists are recommending frenectomies to their patients.  I just turned around and asked my wife if her orthodontist had recommended a frenectomy and she said no.  My orthodontist never recommended a frenectomy either, and I have a large frenum!  Although there is a very small space between my front two teeth, they still touch at the bottom and it’s nothing that would show when people look at me.

One of the leading textbooks in orthodontics, Contemporary Orthodontics by Proffit, addresses the possibility that after the braces come off, teeth may move back to their original position.  He says:

“Another retention problem may be caused by the presence of a large or inferiorly attached labial frenum. A frenectomy after space closure and retention may be necessary in some cases, but it is difficult to determine the potential contribution of the frenum to retention problems from its morphology alone.  Therefore a frenectomy before treatment is contraindicated, and a post-treatment frenectomy should be attempted only if a continued tendency of the diastema to reopen and unresolved bunching of tissue between the teeth show that it is necessary.”

Here he says that a frenectomy should be done only after the space between the front teeth is closed.  He also says that it may be necessary in some cases but that you really can’t tell if the frenum will cause the space to reopen based on its size and shape alone.

In summary, he says that a frenectomy should be done only if the spaces appears to be reopening and you have tissue bunching up between the front teeth (which could cause the space to reopen).

A Labial Frenectomy After Braces – A Pediatrics Perspective

Now that we’ve seen what the orthodontists say about this, let’s turn our attention to the dentists that specialize in treating patients 18 years of age and younger: pediatric dentists.

Dr. Pinkham, in his leading dental pediatrics textbook, Pediatric Dentistry, talks about when and if a frenectomy should be performed.  He says:

“No matter which type of treatment is used to close a midline diastema, retention can be a problem and should be planned. In most cases, a removable appliance maintains the space closure…If the diastema reopens during or following retention, the incisors should be realigned. At that time, a surgical procedure, frenectomy, can be performed if the frenum is thought to be the cause of the diastema’s reopening.”

Just so you know, a diastema is the dental term for a gap between two teeth.

In the above quote, Dr. Pinkham says that a retainer could keep the gap closed after braces in most cases.  He says that a frenectomy should not be done until the diastema reopens after the braces have been removed.  Also, if that is the case, a frenectomy should only be done if the frenum is the suspected cause of the gap reopening.

Conclusion – My Perspective on Labial Frenectomies

As you can see, both Dr. Proffit (the orthodontist) and Dr. Pinkham (the pediatric dentist) both agree that a frenectomy should only be performed after the teeth are moved together with braces and if the frenum is determined to be the cause of the gap. I have to say that I agree with their position on this issue.

It’s important to emphasize again that a frenectomy should not be performed before the space between the front teeth is closed.  Also, a frenectomy should only be performed after it has been determined to be the cause of the space reopening.

If you have any questions about frenectomies, feel free to leave a comment below and I’ll get back to you.

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Videos of Laser Lingual Frenectomies
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A lot of people delay getting things done due to a fear of the unknown.  A few months ago, I wrote about how children might need to get frenectomies.  I think that the whole procedure can be better understood through the use of video.

Lingual Frenum (Courtesy of Enigma51 on Wikimedia Commons)Many people who are tongue-tied don’t want to get a lingual frenectomy because they don’t know if it will hurt, how long it will take, or what will actually happen.

Hopefully the videos below will alleviate those fears. I have embedded three different videos of lingual frenectomies. All of them were performed using laser technology rather than a traditional surgical procedure such as using a high speed drill or using a sharp instrument to cut away the frenal tissue attaching the tongue to the floor of the mouth.

Lingual Frenectomy Videos

This first one shows a young girl getting a lingual frenectomy. The dentist is using an ER:YAG laser to perform the lingual frenectomy procedure. Notice that all the dentist has to do is glide the laser over the tissue and the tissue is mostly cauterized, keeping bleeding to a minimum.

This next video shows the dentist performing a lingual frenectomy with a Periolase Nd:YAG laser.

This final video gives a quick 18-second overview of the whole lingual frenectomy process.

Conclusion

The use of lasers in dentistry has really improved the lingual frenectomy surgical procedure. The laser involves less pain and cauterizes the tissue so that sutures (stitches) aren’t needed.

If you are tongue-tied and you’ve been delaying getting a lingual frenectomy, I hope these videos have helped you.  If you have any questions at all about lingual frenectomies, or if you’ve had one and want to share your story, please do so in the comments section below.

Popping and Clicking in Jaw is Normal
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If you experience a popping sound, a grating sound, or a click when you open your mouth, you’re not alone.

The Temporomandibular JointMany people have slight problems with their jaw joint, which is formally known as the temporomandibular joint, or TMJ for short. Whenever we want to open our mouth, our jaw glides down and forward to allow our mouth to open.

The rounded end of the jaw bone that glides down is called the condyle.  Between the condyle and our skull, there is a small, soft, lubricated disk that allows our jaw to open smoothly.  This is called the articular disk.

Sometimes, that disk may not be big enough, or it may not be the right shape to allow the jaw bone to smoothly glide forward and down when you open your mouth.   When this happens, it is a condition known as crepitus.

Crepitus is a word that is used to describe the grating, crackling, and/or popping sounds that are heard around people’s joints.

Unfortunately, not everyone has jaw joints.  When I open my mouth, my jaw slides down and out nicely on the right side, but on my left side, there is a loud popping noise.  Luckily this only happens when I open my mouth really wide, so it doesn’t affect me when I chew gum or eat (unless it’s a really big hamburger!)

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Anatomy of a Tooth
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Have you ever wondered what makes a tooth so strong?

Anatomy of a ToothThe anatomy of a tooth is very simple compared to the human body.  Every tooth in your mouth has two major portions: a crown and a root.

The crown of the tooth is normally the portion that you can see inside your mouth.  It is covered in a glassy, white-colored substance called enamel, which is the hardest substance in the body.

The root is the part of the tooth that you can’t see unless you have severe gum disease.  It is what anchors the tooth in the mouth and supports all of the forces that are placed on the tooth while food is being chewed.  The root is covered by a very thin layer of a substance called cementum.  The cementum anchors the tooth to the bone by way of the periodontal ligament.

Here is a large diagram that illustrates the anatomy of a tooth:

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Frenectomy in Children Necessary?
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Lisa, a reader from Idaho recently took her children to the dentist.  The dentist remarked that one of her children might need a frenectomy.  Unsure of exactly what a frenectomy was, Lisa opted to learn more about the procedure instead of subjecting her child to surgery.

What is a Frenectomy?

Lingual Frenum and Labial Frenum
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A frenectomy is simply the removal of a frenum in the mouth.  A frenum is a muscular attachment between two tissues.  There are two frena (the plural form of frenum) in the mouth that can sometimes obstruct normal function and are candidates for frenectomies.  These frena are called the lingual frenum, which connects the tongue to the floor of the mouth, and the maxillary labial frenum, which connects the inside of your upper lip to your gums just above your upper two front teeth.

To the right, you can see a diagram of the mouth and the major frena that are present.

Lingual Frenum and Frenectomy

The lingual frenum connects the tongue to the floor of the mouth.  Sometimes, the lingual frenum can run all the way to the tip of the tongue, causing a person to be “tongue-tied.”  This is shown in the photo below:

Lingual Frenum (Courtesy of Enigma51 on Wikimedia Commons)
Note the prominent lingual frenum below the tongue that causes this person to be tongue-tied.

A restrictive lingual frenum is a common occurrence in young children.  Normally, children are able to accommodate well to a prominent lingual frenum and can surprisingly eat and speak normally.  If the attachment is extends all the way to the tip of the tongue, then a frenectomy may be the only choice to give the child normal tongue function.

A lingual frenectomy is a simple procedure and involves numbing the tongue with an anesthetic.  A small incision is then made which will free the tongue from the floor of the mouth.  The incision then will be sewn up to allow the tissue to heal.

Maxillary Labial Frenum and Frenectomy

The maxillary labial frenum attaches the upper lip to the gums just above the upper two front teeth.  If you move your tongue up between your upper lip and your teeth, you will feel this thin band of muscle.

Maxillary Labial Frenum Courtesy of Dale Rosenbach on Wikipedia
A Prominent Maxillary Labial Frenum

A prominent maxillary labial frenum can cause a large gap to occur between the upper two front teeth.  This can be a concern for parents.  However, unless the frenum is causing a lot of pain on the upper lips and gums, immediate treatment is not necessary.  Treatment should be delayed until the upper permanent teeth have come in.  Many times, the replacement of the baby teeth with permanent teeth will naturally close the gap between the two front teeth.  If the gap doesn’t close, then it can be treated using braces, as is shown in the above photo.

If the teeth begin to drift apart again after braces have moved them together, then a maxillary labial frenectomy can be considered if it is determined to be the cause of the gap.  A maxillary labial frenectomy should not be attempted before the gap is closed, because scar tissue can form making it impossible to get rid of the space between the upper two front teeth.

Here is a photo of how a maxillary labial frenectomy looks on the patient that is pictured above:

Maxillary Labial Frenectomy.  Photo Courtesy of Dale Rosenbach.
This maxillary labial frenectomy was performed after the two front teeth had been brought together using braces.

Conclusion

In conclusion, I would recommend only getting a frenectomy when the frenum is obviously causing pain or impeding normal function.

A lingual frenectomy should be considered if a child is having trouble eating, swallowing, or speaking.

A maxillary labial frenectomy should be considered during the “baby teeth years” only if it is causing the child pain.  If the maxillary labial frenum is causing a gap between the upper two front teeth, then a frenectomy should be considered only after closing the gap with braces.  If a maxillary labial frenectomy is performed before the upper two front teeth are moved together, then the subsequent scar tissue could make it impossible to move the upper two front teeth together, leaving the child with a permanent gap between their two front teeth.

If you have any questions about frenectomies, please don’t hesitate to ask them in the comments.